pain management AT GARDEN STATE MEDICAL CENTER
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1 pain management AT GARDEN STATE MEDICAL CENTER Dharam Mann, MD, DABA, DABPM Manjula Singh, MD Suhas Badarinath, MD, DABPMR Laurie Arsenakos, APN-C Dana Pratola, APN-C Specializing in Minimally-Invasive Interventional Pain Management How did you hear about us? Please check all that apply. My Physician told me about you Friend, family or co-worker I saw your billboard Welcome to our Practice Newspaper Ad: Magazine Article: Drive-by/Saw Sign Website or Internet Other: PATEINT DEMOGRAPHIC INFORMATION Patient s Name of Birth Today s Social Security Number Gender Weight Marital Status M F Home Phone Prefer. Phone Single Married Partner Divorced Widdow Cell Phone Home Cell Emergency Contact Leave Message Yes No Referring Physician Name, Phone # Primary Care Physician Name, Phone # Employment Status Employer/School Name Employed Unemployed Student Retired Military Disability Race American Indian or Alaska Native Asian Black or African American White Hispanic Other Race No Answer Ethnicity Spoken Language Address Hispanic or Latino Not Hispanic or Latino No Answer English Spanish Other PRIMARY INSURANCE INFORMATION Insurance Company Name, Phone # ID# Group # Claims Address, City, State, Zip Policy Holder s Name, Phone # Address, City, State, Zip SECONDARY INSURANCE INFORMATION Insurance Company Name, Phone # ID# Group # Claims Address, City, State, Zip Policy Holder s Name, Phone # Address, City, State, Zip PRESCRIPTION PLAN Insurance Company Name, Phone # ID# Group # Claims Address, City, State, Zip IS THIS A WORKMAN S COMPENSATION OR MOTOR VEHICLE CLAIM? of Accident Adjustor Name Company Name, Phone # Claim # Yes No Page 1 of 6
2 Understanding Your Rights ASSIGNMENT OF BENEFITS AND MY FINANCIAL RESPONSIBILITY It is the policy of Garden State Pain & Radiology to collect payment at the time of visit. If you have a policy with a company with which we have a contract, we will gladly file your claim for you. However, you are expected to pay any co-pay to deductible at the time of service. If your carrier is out of network, you are expected to pay at time of service, unless arrangements have been made with the financial advocate. I understand that I am responsible for any co-insurance fees/charges, if it is not covered by a secondary. I understand that my insurance company may send payments for the rendered services to me. I hereby assign to Garden State Pain & Radiology all surgical, medical Insurance and other benefits, if any, otherwise payable to me for the services. I agree to endorse the check(s) over to Garden State Pain & Radiology. I understand that if I use the insurance proceeds for my personal use, I have committed Insurance fraud. I hereby authorize and direct payment directly to Garden State Pain & Radiology from the obligor of said benefits. Further, I hereby assign and convey Garden State Pain & Radiology, unless charges for the services have been paid, so much of any cause of action or right of recovery and any payment proceeds relating thereto, that I may have against any third party and direct my attorney, if one has been retained as well as any person to insurance company obligated to pay damages or restitution to me, to deduct the amount of any outstanding bill for Garden State Pain & Radiology any settlement proceeds or other proceeds to be paid directly to me prior to receiving said proceeds. I understand that payment is due when services are rendered unless prior arrangements have been made. I assign all medical and/or surgical benefits including major medical benefits for services provided to Garden State Pain & Radiology. This assignment will remain in effect until revoked by me in writing. I am aware that any charges NOT COVERED by my insurance policy are my responsibility. I further understand that should any account with Garden State Pain & Radiology be turned over to a collection agency, I will be responsible for any additional interest on my outstanding balance or charges that may be incurred in the collection of my account. IDENTIFICATION PHOTOGRAPH AUTHORIZATION Initals I give permission for Garden State Pain & Radiology Center to take an identification photograph to be maintained in my medical records. I understand that this picture will be used in a confidential manner related only to my personal care in the above named office. PRIVACY PRACTICES I have received a copy of Garden State Interventional Pain Management Privacy Practices. I have had the opportunity to have any questions answered regarding the privacy practices of the doctor s office. Page 2 of 6
3 Assignment of Benefits Form Practice Name: Garden State Pain & Radiology Center Address: P.O. Box 397, Whiting, NJ Phone: Patient s Name Social Security Number Insurance ID Number Insurance Claim Group Employer I hereby instruct and direct Insurance Company to pay by check made out and mailed to: GARDEN STATE PAIN AND RADIOLOGY CENTER P.O. Box 397, Whiting, NJ Or If my current policy prohibits direct payment to Doctor, I hereby also instruct and direct you to make out the check to me and mail it to the temporary address as follows: Patient Name C/o GARDEN STATE PAIN AND RADIOLOGY CENTER P.O. Box 397, Whiting, NJ For the professional or healthcare expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize Doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf. Witness Page 3 of 6
4 Understanding Your Rights PAIN MANAGEMENT AGREEMENT The purpose of this agreement is to prevent misunderstandings about certain medicines you will be taking for pain management. This is to help both you and your doctor to comply with the law regarding controlled pharmaceuticals. I understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this agreement I understand that if I break this agreement, my doctor will stop prescribing these pain control medicines. In this case, my doctor could taper off the medicine over a period of several days, as necessary, to avoid withdrawal symptoms. This is at the discretion of the physician. Also, a drug dependence treatment program may be recommended. I have communicated, and I will continue to communicate fully with my doctor about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. I will inform my doctor at Garden State Pain & Radiology of all the medications I am presently taking, including all remaining refills, and I will not attempt to obtain any controlled medicines, including opioid pain medications, controlled stimulants, antianxiety and/or Suboxone medicine from any other doctor. I authorize Garden State Pain and Radiology and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this states Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize Garden State Pain and Radiology to provide a copy of this agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentially with respect to these authorizations. I will not use any illegal controlled substances including: marijuana, cocaine, etc. I will not drink alcoholic beverages while taking narcotic medications. I will not share, sell or trade my medication with anyone. I will safeguard my pain medicine from loss or theft. Lost or stolen medicine will not be replaced, and I understand that Garden State Pain & Radiology Center reserves the right to terminate my care if I fail to follow the protocol following such an incident. I Agree that I will submit to a blood, urine and/or oral swab test as well as random pill count, if requested by Garden State Pain & Radiology Center, to determine my compliance with my treatment program. I understand that Garden State Pain & Radiology Center reserves the right to terminate my care and treatment in this office if I fail to comply or refuse any type of screening. I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medication for a period of time or in termination of my medical care and treatment in this office. I will bring my pain medication to every office visit to be subject to a pill count. I agree that refills of my prescriptions for pain medicine will be made only at the time of a scheduled office visit. No refills will be made available during evenings or weekends. I AGREE TO ONLY USE THE FOLLOWING PHARMACY FOR FILLING PRESCRIPTIONS FOR ALL OF MY PAIN MEDICINE. Pharmacy Name Phone Address, City, State, Zip I agree to follow these guidelines that have been fully explained to me, and I have received a copy of this agreement. All of my questions and concerns regarding treatment have been adequately answered. IF I FAIL TO COMPLY WITH ANY OF THE ABOVE, GARDEN STATE PAIN AND RADIOLOGY RESERVES THE RIGHT TO TERMINATE MY MEDICAL CARE AND TREATMENT. Page 4 of 6
5 Medical Release Form PATIENT INFORMATION Patient s Name Social Security Number Today s of Birth I grant my permission for Garden State Pain & Radiology to speak with and/or release information regarding my medical treatment and/or condition to the following persons/medical offices: Page 5 of 6
6 (732) pain management (732) diagnostic imaging The Leader in Pain Management & Diagnostic Imaging (732) main fax HIPAA AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION This form will allow us to obtain any necessary medical information necessary to diagnose and treat the listed patient. PATIENT S INFORMATION Patient s Name of Birth Social Security Number Street Address City, State Zip INFORMATION TO BE RELEASED: This authorization includes release of information concerning treatment of psychiatric/ psychological conditions, drug and/or alcohol related conditions, and HIV or AIDS related conditions. Discharge summary History & Physical Face sheet Emergency Department Record Operative reports Pathology reports Laboratory reports Immunization/shot records Outpatient records Itemized bill Neuropsychological reports Psychological reports X-ray/Medical Imaging Report Entire medical record Other: THE ABOVE INFORMATION IS TO BE RELEASE TO: Garden State Pain & Radiology Center 1100 Route 70 West Whiting, NJ FOR THE PURPOSE OF: Continued medical care Personal interest Legal claim processing Insurance claim processing External quality/ utilization review Other: Patient Guardian/Authorized Representative Witness Page 6 of 6
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Patient Registration Form
Patient Registration Form MRN #: Patient Name: Provider: Sort ID: DOB: Date: Address Home Phone Cell Phone Work Social Security Number Date of Birth Male Female E-mail Address Is your visit today due to
You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)
Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.
Patient Information: In Case of Emergency: Physician: Insurance:
For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:
Advanced Women's HealthCare, SC Registration Form
Patient Full Name Address Advanced Women's HealthCare, SC Registration Form Street Account # Provider Last First Middle Maiden(0ther) Apt/Suite# City State Zip Code Phone # (Please circle preferred contact
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
Brain & Spine Center of Texas, L.L.P. Dallas Minimally Invasive Spine
Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth Social Security # Male / Female Race Ethnicity (Latino / Non Latino)
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net
360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on
Ohio Victims of Crime Compensation Program Application for Crime Victim Compensation
Ohio Victims of Crime Compensation Program Application for Crime Victim Compensation Please type or print using blue or black ink After an application has been filed, the law may provide for payment of
Ohio Victims of Crime Compensation Program
Ohio Victims of Crime Compensation Program Application for Compensation If you or your family members are innocent victims of a violent crime, financial assistance may be available. The Ohio Victims of
I have received a copy of the Notice of Privacy Practices True Health.
Sign-in Time: I have received a copy of the Notice of Privacy Practices True Health. Signature of Patient/Patient Representative Relationship of Patient Representative to Patient 2400 State Road 415 11881-A
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012)
ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA 98223 360-403-0333 360-403-0331FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print
PATIENT INFORMATION. Male Female ( ) / / Street Address / P.O. Box: City: State: Zip Code:
Today s : PATIENT INFORMATION Patient s Last Name: First: Middle: Mr. Miss Mrs. Ms. Dr. Home phone no.: Cell phone no.: Work phone no.: Birth : Marital Status (check one) Single Separated Married Widowed
Victim Information. Other Information. How did you find out about the CVCP? Check the box that applies: Police/Law Enforcement
Department of Labor and Industries Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 Email: CrimeVictimsProgramM@LNI.WA.GOV Fax: (360) 902-5333 Crime Victim s Application for Benefits
How To Care For An Endocrine Patient
I have known since ninth grade in high school that I wanted to be a physician, specifically, an endocrinologist. To accomplish this I graduated from high school second out of 450 and then attended the
INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES
INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY
FAMILY CONTACT INFORMATION
FAMILY CONTACT INFORMATION -------------------- PLEASE COMPLETE THIS FORM IN BLACK INK ONLY -------------------- Date Account # Children Names DOB Gender School Goes By Cell Phone # Email Address Please
CRIME VICTIM S REPARATION CLAIM FORM INSTRUCTIONS
CRIME VICTIM S REPARATION CLAIM FORM INSTRUCTIONS In order to process your claim for compensation, the following information is needed: 1. The claim for compensation must be thoroughly and accurately completed.
HSE Medical Associates Family Practice
HSE Medical Associates Family Practice PLEASE CHECK WHICH PROVIDER YOU ARE HERE TO SEE M.D. P.A. David W. Hoefer, M.D. Paul E. Shepard, M.D. Alfredo T. Ermac, M.D. Sergio G. Perossa, Darcy Bevil, P.A.
ATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT
STATE OF GEORGIA ATTORNEY-CLIENT WORKERS COMPENSTATION FEE CONTRACT AND AUTHORIZATION TO REPRESENT I,, with a Social Security Number of the undersigned, do hereby retain the Ramos Law Firm, LLC, located
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
Welcome to our office. Providing you with exceptional care is the motivation and intention of our physicians and staff.
451 N. Texas Ave. 1401 Binz St, Suite 200 20320 Northwest Fwy. #700 Webster, TX 775988 Houston, TX 77004 Houston, Texas 77065 Stephen Tyring, MD, PhD Karan Sra, MD Lauren Campbell, MD Payel Patel, DO NEW